28 CA ADC § 1300.52.4


      28 CCR s 1300.52.4

      Cal. Admin. Code tit. 28, s 1300.52.4


      CALIFORNIA CODE OF REGULATIONS
      TITLE 28. MANAGED HEALTH CARE
      DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
      CHAPTER 2. HEALTH CARE SERVICE PLANS
      ARTICLE 3. PLAN APPLICATIONS AND AMENDMENTS
      This database is current through 06/09/06, Register 2006, No. 23.

      s 1300.52.4. Standards for Amendments and Notices of Material 
Modification.

      Notwithstanding anything to the contrary in Sections 1300.52, 1300.52.1, 
      1300.52.2, and 1300.52.3, the following standards shall apply to 
      amendments and notices of material modification to a plan license 
      application once a health care service plan has been issued its license. 
      These standards shall apply to full-service health care service plans and 
      specialized health care service plans.

      (a) General Statement of Requirements.

      (i) If a plan makes a change that (A) constitutes an amendment to its plan 
      license application and (B) is not listed in subsection (d) of this 
      Section 1300.52.4, then the plan shall file an amendment with the 
      Department. If the plan makes a change that is listed in subsection (d) of 
      this Section 1300.52.4, then the plan shall file a notice of material 
      modification with the Department.

      (ii) The plan shall include in any amendment or notice of material 
      modification any document or other information specifically required by 
      one of the items set forth in Section 1300.51, which is pertinent to the 
      amendment or material modification. Other information may be required if 
      it is determined by the Department to be necessary in order to make a 
      finding under the Act that the amendment or material modification is in 
      the public interest and consistent with the intent and purpose of the Act.

      (b) Specific Standards for Amendments.

      (i)(A) In the event of any change to one or more of the items specified in 
      Section 1351 of the Act, the plan shall file an amendment to its plan 
      license application within 30 days after the plan implements that change, 
      unless the change requires the filing of an amendment pursuant to clause 
      (ii) of this subsection (b) or a notice of material modification pursuant 
      to subsection (d) of this Section 1300.52.4. A change that is the subject 
      of an amendment required to be filed pursuant to this subsection shall 
      become effective on the date implemented.

      (B) Notwithstanding the immediately subsection (b)(i)(A) of Section 
      1300.52.4: (I) if the plan has not been continuously licensed under the 
      Act for the preceding 18 months and has not had group contracts in effect 
      at all times during that period, then, to the extent the amendment 
      includes any new or modified plan contract, disclosure form, or evidence 
      of coverage, the change shall not be effective until 30 calendar days 
      after the date the amendment was filed with the Department; and (II) to 
      the extent the amendment includes any new or modified plan contract, 
      disclosure form, or evidence of coverage that relates to an individuals 
      health care service plan contract, the change shall not be effective until 
      30 calendar days after the date the amendment was filed with the 
      Department.

      (ii) In the event of any change described in Section 1352(c) of the Act, 
      the plan shall file an amendment in accordance with the requirements of 
      Section 1300.52.2. A change that is the subject of an amendment required 
      to be filed pursuant to this subsection (b)(ii) shall be effective on the 
      date implemented.

      (c) Limited Enforcement or Disciplinary Action in Specified Circumstances 
      Regarding Amendments.

      If the Department does not provide objections to a plan with regard to an 
      amendment within 30 days after the plan files the amendment, the 
      Department may require the plan to make changes to comply with the Act and 
      the rules adopted under the Act. The Department shall not take any 
      disciplinary action or begin any other enforcement action against the plan 
      with regard to the implementation of the changes described in the 
      amendment, unless the material or any portion of the material was 
      previously disapproved or otherwise objected to in writing by the Director 
      or the plan knew or should have known that the material or any portion of 
      the material violated any provision of the Act or the rules promulgated 
      thereunder.

      (d) Specific Standards for Notices of Material Modification.

      If a plan proposes to make any of the following changes, the plan shall 
      file a notice of material modification with the Department.

      (i) An expansion, or a contraction or reduction, of the plan's approved 
      service area.

      (ii) The offering of a new health care service plan contract by the plan 
      in any service area if the plan proposes to use a network of providers 
      that is materially different from the network used for any other plan 
      contract currently being offered by the plan.

      (iii) A merger, consolidation, acquisition of a controlling interest, or 
      sale of the plan or of all or substantially all of the assets of the plan, 
      directly, or indirectly.

      (iv) The plan's initial offering of a plan contract for small employers, 
      which requires the filing of a notice of material modification pursuant to 
      Section 1357.15 of the Act. A subsequent change with regard to the plan's 
      small employer plan contracts shall be filed as an amendment pursuant to 
      subsection (b) of this Section 1300.52.4, unless the change otherwise 
      would require the filing of a notice of material modification.

      (v) The plan's initial offering of a point-of-service contract, which 
      requires the filing of a notice of material modification pursuant to 
      Section 1374.69 of the Act. A subsequent change with regard to the plan's 
      point-of-service plan contracts shall be filed as an amendment pursuant to 
      subsection (b) of this Section 1300.52.4 unless the change otherwise would 
      require the filing of a notice of material modification.

      (vi) A change of plan name, which requires the filing of a notice of 
      material modification pursuant to Section 1300.66.

      (vii) A change that would have a material effect on the plan or on its 
      health care service plan operations.


      


      Note: Authority cited: Section 1351, Health and Safety Code. Reference: 
      Sections 1352 and 1352.1, Health and Safety Code. 


       HISTORY 
         
      1. New section filed 11-30-98; operative 11-30-98 pursuant to 
      GovernmentCode section 11343.4(d) (Register 98, No. 49).

      2. Change without regulatory effect amending subsection (c) filed 
7-18-2000
      pursuant to section 100, title 1, California Code of Regulations (Register
      2000, No. 29).
      28 CA ADC s 1300.52.4

      END OF DOCUMENT

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